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2023 International Collaboration and Exchange Program Registration Form
Registration form for program participants- Before you sign up :1) please ensure that you will have time to commit to the full program for the small group sessions and the large group conferences (you will meet once in the small group and 2-3 times in the large group per month mostly on weekends); 2) if your school needs permission to participate please ensure your ICE program faculty approved. Selection is very competitive. If you get accepted into the program we expect full commitment until the end of the program. Registration will close 10/7/23 for all US schools, 10/10/23 for all schools except the University of Milan and select University of Cambridge students.
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* Indicates required question
Email
*
Your email
Region where you study
Africa
North America
Europe
Asia
Australia
Other:
Clear selection
Name (first and last)
*
Your answer
Email address 1 (school email)
Your answer
I am a student at
*
Berlin Charite University, Berlin, Germany
Chinese University of Hongkong (you can only participate in the virtual portion - no exchange travel or research option, please do not select options)
Columbia University, New York, USA
Harvard Medical School, Boston, USA
Keio University, Tokyo, Japan
King's College, London, UK
Kyoto University, Japan
Ludwig Maximilians University, Munich, Germany
Martin Luther University, Halle, Germany
McGill University, Canada
Medical University of Vienna, Austria
National Taiwan University, Taipei, Taiwan
National University of Singapore, Singapore
Nazarbayev University, Astana, Kazakhstan
Seoul National University, Seoul, Korea
Stanford University, Stanford, USA
The University of Sydney, Australia
Tokyo Women's Medical University, Japan
University Autonoma Madrid, Madrid, Spain
University of Barcelona, Barcelona, Spain
University of California San Francisco, USA
University of Cambridge, Cambridge, UK
University of Copenhagen, Denmark
University of Helsinki, Finland
University of Paris Cite, or Sorbonne University Paris, France
University of Lausanne, Lausanne, Switzerland
University of Milan, Milan, Italy
University of Nairobi, Nairobi, Kenya
Yale University, New Haven, USA
Not listed (see next question)
Other:
If your university is not listed please list here (we will evaluate case by case if you can be included in this year's cohort)
Your answer
I am a (check all that applies to you)
*
medical student
dental student
MD PhD student
MD MS student
College premedical student
College student (Laidlaw Program student on science or premedical track)
Public Health student
Graduate student in health sciences (PhD candidates)
PhD nursing student
Biomedical sciences student
Pharmacy student
Other
Other:
Required
I am
female
male
non-binary
prefer not to disclose
Other:
Clear selection
Email address 2 (private email as back up that you frequently check- we will primarily use your school email)
Your answer
I am an international student at my school. I am originally from ..... (list your country and/or citizenship). We want to include many different countries! Type "no applicable" if you are a citizen in the country where you study.
Your answer
I am
between 18 and 20 years old
between 20 and 25 years old
over 25 years old
under 18 years of age
prefer not to disclose
Clear selection
Enter your year of school
*
Preclinical medical
Clinical medical
Preclinical dental
Clinical dental
MD PhD student
MD MS student
College student (premedical)
Biomedical or health science (nonclinical)
Other:
Enter your year of school
*
1 of 4 year program
1 of 5 year program
1 of 6 year program
2 of 4 year program
2 of 5 year program
2 of 6 year program
Undergraduate college (premedical)
3 of 4 year program
3 of 5 year program
3 of 6 year program
4 of 4 year program
4 of 5 year program
4 of 6 year program
final year student
college premedical student (not in medical/dental/graduate school yet)
not listed
Other:
Phone number (start with country code)
Your answer
Whatsapp number or email (if you have)
Your answer
Slack name. Please note that the program uses Slack for communication. If you do not use Slack please indicate so here.
*
Your answer
Faculty approval obtained (please note, that for some schools students can only travel if pre-approved by local Faculty. You can still participate in the virtual portions of program without Faculty approval, but you may not travel).
*
Yes (you need to contact your local faculty member to have your name included in application list)
No
Not needed at my school (Columbia, Cambridge, Yale, Stanford, UCSF, Harvard)
Other:
Faculty name who approved (not applicable if none)
*
Your answer
Are you willing to serve as a group leader for your small group? "Yes" is a full commitment.
*
Yes
No
Are you willing to serve as a National Student Leader for your school (National Student Leaders serve as the contact for your cohort at your school, organize local meet ups, convey questions to your cohort members and communicate with the senior student leaders of the program)?
*
Yes
No
Summer 2024 travel exchanges. Are you interested in the International Collaboration and Exchange Program in person exchange travels?
Only students who attend and participate actively in all global weekends and small group meetings, participate in discussions and debates are eligible
. Most schools have limited slots. There will be a follow-up questionnaire in December for students to confirm their travel preferences. Based on the December questionnaires slots will be assigned. Schools can send as many students as they accept. The travels are self-funded or via school grants or research scholarships (please inquire with your schools)
Yes - I commit to travel and will secure funding
No
Undecided
Other:
Clear selection
I commit to the full program and will check my email and the website for updates. If I need to drop out I will notify my National Student Leaders, my group and the program at ICEglobalprogarm@gmail.com immediately. If I understand that if I drop out without telling anyone my peers from my small group will not be invited to travel.
*
Yes
No
I consent that photos taken at the virtual conferences can be published with my name and face on it. We publish on Instagram and our website.
*
Yes
No
Program selection question - in a short essay (3-5 sentences max) outline why you would like to participate in the program. Share with us your goals and why you think you are a good candidate for this program (this essay will be used to select your participation)
*
Your answer
I confirm to commit to the full virtual portion of the program. - Please note that the program has limited participation slots for each university and that you are taking away a slot for another student by dropping out. If you miss 3 sessions you will be removed from the program and cannot list this activity in your CV or be placed for travels.
*
I understand and confirm to commit to the full virtual program. If there is an emergency I will let the program and my senior leaders know.
Do not forget to fill out the pre program questionnaire:
https://cumc.co1.qualtrics.com/jfe/form/SV_a8YMYpE57B6GHVs
*
Yes, I have filled out the questionnaire
No, I decline participating in the questionnaire
No, but I will fill it out prior to the start of the program
Other:
Any questions or comments before we start? The program will start in October. Please email ICEglobalprogram@gmail.com if you do not hear back from us with confirmation for participation by October.
Your answer
A copy of your responses will be emailed to the address you provided.
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